INFECTIOUS DISEASES IN CHILDREN Andi Marmor, MD, MSED - - PowerPoint PPT Presentation

INFECTIOUS DISEASES IN CHILDREN

Andi Marmor, MD, MSED Associate Professor of Pediatrics University of California, San Francisco San Francisco General Hospital Acknowledgement: Hayes Bakken, MD

I HAVE NOTHING TO DISCLOSE.

Updates and Current Recommendations

 Fever without a source (SBI)  Urinary Tract Infections  Acute Otitis Media  Influenza  Pertussis  Community Acquired PNA  Bronchiolitis

FEVER COUGH

 TB  Vaccinations

RASHES SCREENING/PREVENTION

Case Presentation: Infant with Fever

Serrano is 2 week old girl with a fever No symptoms to suggest a source on

exam/history

VS: T 38.5, P 150, R 40’s, o/w WNL Exam: well-appearing, no focal findings

to suggest source for fever

The most likely cause of Serrano’s fever is:

A.

Viral infection

B.

Urinary tract infection

C.

Serious bacterial infection (bacteremia/meningitis)

D.

HSV infection

Viral infection Urinary tract infection Serious bacterial infecti.. HSV infection

59% 0% 10% 32%

THE FEBRILE INFANT

Everything you need to know about SBI in febrile infants - on ONE SLIDE

Schwartz, 2009, Gomez 2010, Greenhow, 2014

2-3%

E.Coli>GBS>S. aureus >enterococcus, S pneumo

13-18% <1%

Greenhow, 2014

• E. Coli

E.Coli/GBSS. pneumo

Fever without a source (FWS): Infants <30 days

Appearance and lab criteria do not reliably

rule out UTI/SBI in this age group

Urine, blood, CSF, empiric abx

recommended

Amp/cefotaxime or amp/gentamicin

FWS: Infants 30-90 days

 UTI still the most common bacterial source,

• ther SBI less likely

 Viral source more reliable

Named viral syndromes or + rapid viral test

(flu, RSV) SBI unlikely

Consider testing for UTI

 Inflammatory markers (CBC/CRP/PCT)

helpful in select infants

Well appearing infants with neg UA AND no

viral source

• Infant well-appearing?

Stabilize, obtain cultures, start antibiotics Infant > 30 days? Infant > 90 days? Close follow up Obtain urine for UA and culture Obtain rapid viral test if available Start treatment for UTI/pyelo

• Consider obtaining blood

culture if < 2 mo Obtain blood for culture and inflammatory markers Close follow up Ceftriaxone Close follow- up

• Consider LP if meningeal

signs/symptoms

yes no no no yes yes RVT+ UA- RVT- UA+

Supportive care and follow up

Markers WNL WBC > 15 or < 5 CRP > 20mg/L PCT > 0.5ng/mL

Approach to FWS in Infants:

Case Continued

Since Serrano is less than 30 days, and

has no source for her fever, you obtain a UA/urine cx and blood cultures and perform an LP

Her UA is positive for LE and nitrites Now what do you do?

URINARY TRACT INFECTIONS

Who is at risk for UTI/pyelonephritis?

 All infants with FWS < 3 mo of age  Girls > 3 mo of age

FWS (>39) and < 24 months

 Boys > 3 mo of age

Circumcised: FWS (>39) and < 6 mo Uncircumcised: FWS (>39) and < 12 mo

 Additional Risk Factors:

Race (non-black) Length of fever (> 2 days)

2011 AAP Guidelines: Diagnosis

Collect urine for UA and cx by catheter for:

Infants < 3 mo of age (high risk) Ill-appearing infants or those requiring empiric

antibiotics for another reason

Consider bag collection for:

Low-risk infant (eg: circ boy> 3 mo) If UA +, consider cath for culture

Roberts 2011;Pediatrics128(3):595–610

2011 AAP Guidelines: Treatment

 Empiric treatment: Based on local E. Coli resistance

PO and IV routes are equally efficacious

IV if <2 mo, toxic or not tolerating PO

Total course: 7-14 days

 Imaging after UTI (highest yield in youngest

infants)

U/S recommended (although prob not necessary)

~15% abnormal, 1-2% actionable, 2-3% false positives

Voiding Cystourethrogram (VCUG) if:

High grade VUR/obstruction on U/S (yes) > 1 episode of febrile UTI (?)

Roberts 2011;Pediatrics128(3):595–610

Case Continued

Serrano’s 2 yo brother Aleppo has also

had a runny nose and cough for 3-4 days, and Tmax of 38.5

Last night he started pointing at his ear

saying “owie”, and mom is concerned that he has an ear infection

What would you do next?

ACUTE OTITIS MEDIA

2013 AAP Guidelines: Acute Otitis Media

Diagnosis requires

Moderate to severe bulging OR new otorrhea Mild bulging AND

Recent onset ear pain OR Intense erythema of the Tympanic Membrane

Lieberthal; Pediatrics 2013

Normal Mild bulging Moderate bulging Severe bulging

AAP Guidelines: Treatment

Treatment guided by age and severity

Age Non-severe Severe*

6- 23 months Unilateral: observe or treat Bilateral: treat Treat 2-12 yrs Observe or treat Treat

 Severe symptoms include:  Temperature >39  Moderate-severe otalgia  Otalgia > 48 hours

AAP Guidelines: Antibiotics

 First Line: Amoxicillin (80-90 mg/kg/day)

Amoxicillin-Clavulanate (90m/k/d amox +6.4 m/k/d clav)

If Amoxicillin in previous 30 days, + conjunctivitis

Cephalosporins: Cefdinir, cefuroxime, cefpodoxime

May have slightly lower efficacy against S. pneumoniae  Treatment failure = persistent sx for >48-72h

Amoxicillin-Clavulanate or IM Ceftriaxone Consider drainage, culture, specialist

 Tubes: > 3 infections/6mo OR 4 in last year

Lieberthal; Pediatrics 2013

Case continued

You decide to treat Aleppo’s OM

supportively, but since he is febrile with cough, you are also concerned about flu

He is well-appearing, with normal vital

signs, and no resp distress

He used an inhaler at 6 mo with a viral

infection, no other PMH, has not yet received flu shot

Should you test him for influenza?

INFLUENZA

Influenza- Associated Pedi Deaths

CDC, 2016

Current season…

CDC, 2016

Who to Test/Treat (RVT= 60% sens/98% spec)

 Treat WITHOUT testing: clinical suspicion AND  Moderate/severe illness  High risk for severe disease (<2yrs, chronic disease,

immunosuppressed, chronic ASA therapy)

 Test and treat only if +  When you will do something with the result  Otherwise healthy AND <48 hrs of illness  Regimens  Oseltamivir (Tamiflu) weight based dosing BID x 5 d  Zanamivir (Relenza) disk inhaler for children > 7 yo

Our patient=unlikely to benefit

Influenza: Prevention

 Who to immunize: everyone > 6 mo

If < 8, give 2 doses for the FIRST season only

 IM (Inactivated – IIV) vs nasal (Live – LAIV)

Recent studies show equal efficacy IIV ONLY if < 2, immunosuppressed

 Contraindications: LIFE-THREATENING egg

allergy or previous reaction to vaccine

ACIP recs for 2015/16 season: http://www.cdc.gov/flu/professionals/acip/index.htm

Case Presentation: 3 yo with cough

Sorrel is a 3 yo who presents with 2

weeks of cough, keeps her awake, and

• ccasional post-tussive vomiting

She has a PMH of bronchiolitis (6 mo) and

is up to date for age on vaccinations

VS: T 38.2, P 130, RR 42, O2 sat 95% Her mother wants to know if this could be

“the whooping cough”

PERTUSSIS

Pertussis Epidemiology

Tdap Acellular pertussis

Phases of Pertussis

PHASE TIME COURSE DESCRIPTION Catarrhal 1-2 weeks Mild fever, cough, rhinorrhea Paroxysmal 1-6 weeks Older infants/children: Paroxysms, whoop, post-tussive emesis Young infants: apnea, cyanosis, bradycardia, poor feeding Convalescent Weeks-Months Improvement in severity and frequency of coughing episodes

Slide courtesy of Ellen Laves, MD

Pertussis: Clinical Diagnosis

Cough lasting >2 weeks + 1of the following:

Apnea* Paroxysms of coughing Inspiratory “whoop” Post-tussive vomiting (least specific)

cdc.gov/pertussis

Older children *May occur without cough Neonates/young Infants

Pertussis: Laboratory Confirmation

Lab confirmation ONLY in those with

signs/symptoms consistent with pertussis

Posterior NP specimen (not pharynx/ant NP) PCR for pertussis

False positives may occur

Culture + for B. Pertussis

Most SPECIFIC test

Most sensitive in first 3 weeks

cdc.gov/pertussis

Pertussis: Treatment

 Major benefits:

Prevent severe disease* in those at risk Prevent spread to high risk (HR) patient

 Empiric treatment: high suspicion and/or HR

Infants <1 year (< 3mo, preemie at highest risk) Pregnant women near term Unimmunized or underimmunized

 Test and treat if +:

HR but low clinical suspicion Patient LR but has HR contacts

*Only treatment BEFORE paroxyms may shorten course

Case Continued

Sorrel’s vaccination status and non-

specific clinical symptoms make pertussis less likely

However, her RR (42) and O2 sat (95%)

make you concerned for pneumonia

Well-appearing, in minimal resp distress

aside from tachypnea

Decreased breath sounds with crackles over

the LLL

What is the RECOMMENDED next step?

A.

Obtain a PA and lateral CXR

B.

Obtain a blood culture and CBC

C.

Obtain a sputum culture

D.

Start PO amoxicillin and discharge with close follow up

E.

Start IV cefuroxime and admit

O b t a i n a P A a n d l a t e r a l C X R O b t a i n a b l

• d

c u l t u r e a . . O b t a i n a s p u t u m c u l t u r e S t a r t P O a m

• x

i c i l l i n a n d . . . S t a r t I V c e f u r

• x

i m e a n d . . .

55% 7% 1% 34% 1%

COMMUNITY ACQUIRED PNEUMONIA

Community Acquired Pneumonia: Diagnosis

Clinical

Symptoms of acute illness (ie: fever) + resp

distress (tachypnea*, retractions, hypoxia) AND

Focal lung findings on exam OR on CXR

Imaging

Chest x-ray NOT recommended routinely in

• utpatients

Does not distinguish between pathogens (viral,

atypical, etc)

Bradley JS, et al. Clin Infect Dis. 2011

*MOST SENSITIVE sign

Community Acquired Pneumonia: Laboratory Diagnosis

 Routine lab testing NOT recommended  Blood cultures:  Clinically worsening or hosp with mod/severe disease  Viral testing (flu, RSV)  IF no evidence of bacterial co-infection  CBC/CRP  Not recommended  Testing for Mycoplasma pneumoniae, S. pneumo  If available, may guide antibiotic selection

Bradley JS, et al. Clin Infect Dis. 2011

Community Acquired Pneumonia: Treatment

Viral is most common < 2 yrs: S. pneumoniae, C.

Trachomatis

2-5 yrs S. pneumoniae, M.

pneumoniae, H influenzae,

• C. pneumoniae

 M. pneumoniae, C.

pneumoniae

 S. pneumoniae

2 MO TO 5 YRS: OVER 5 YEARS:

Bradley JS, et al. Clin Infect Dis. 2011

Based on age, severity, local resistance

Community Acquired Pneumonia: Treatment

 Inpatient or Outpatient 1st line treatment:

Amoxicillin/ampicillin in infants and young children Macrolide (azithro) in kids > 5

 Ill patent or high-level PCN resistance:

3rd generation cephalosporin if suspect S. pneumo Vancomycin if suspicion for MRSA +Macrolides if suspicion high for M. pneumoniae

and C. pneumoniae

Bradley JS, et al. Clin Infect Dis. 2011

What is the RECOMMENDED next step?

A.

Obtain a PA and lateral CXR

B.

Obtain a blood culture and CBC

C.

Obtain a sputum culture

D.

Start PO amoxicillin and discharge with close follow up

E.

Start IV cefuroxime and admit

Case Continued

As you are explaining Sorrel’s discharge

plan to her mother, she asks you to check on baby brother Sumac who also has a “cold”

The 9 month old is alert and well-appearing

RR of 55, T of 38.5, O2 sat of 91% Moderate retractions, coarse wheezes and

rhonchi throughout on exam

You are concerned about bronchiolitis: what is the next step in diagnosis?

A.

RSV test

B.

Chest Xray

C.

Response to albuterol

D.

Response to hypertonic saline

E.

Nothing, you have already made the diagnosis

R S V t e s t C h e s t X r a y R e s p

• n

s e t

• a

l b u t e r

• l

R e s p

• n

s e t

• h

y p e r t

• n

i c . . . N

• t

h i n g , y

• u

h a v e a l r e . . .

44% 1% 33% 4% 18%

BRONCHIOLITIS

Bronchiolitis

Virally-mediated inflammation, edema,

and epithelial necrosis in small airways

50-75% caused by RSV

rhinovirus > influenza > Human

metapneumovirus > coronavirus

Etiology correlates poorly with severity

Most common reason for admission in

children

Bronchiolitis: 2014 AAP Guidelines

Clinical Diagnosis

Upper respiratory prodrome followed by

increased WOB, wheezing, hypoxia, classic lung exam

Radiographs and lab studies are not routinely

recommended

Ralston, SL et al Pediatrics. 2014

You are concerned about bronchiolitis: what is the next step in diagnosis?

A.

RSV test

B.

Chest Xray

C.

Response to albuterol

D.

Response to hypertonic saline

E.

Nothing, you have already made the diagnosis

What should you do for Sorrel?

 Treatment:

Albuterol trial: only if dx uncertain Corticosteroids, racemic epi: not routinely

recommended

Hypertonic saline: studies mixed, some evidence

for shortened inpatient stay when given with bronchodilators

 Monitoring

Continuous pulse ox not required Supplemental O2 only for persistent < 90%

Ralston, SL et al Pediatrics. 2014

Bronchiolitis: 2014 AAP Guidelines

Febrile infants > 30 days

Do not need additional workup Consider UA/cx

Prophylaxis: palivizumab (Synagis)

Preterm infants: gestational age <29 wks CHD/CLD: < 12 months old (<24mo if

getting medical therapy)

5 monthly doses/season

Ralston, SL et al Pediatrics. 2014

Bronchiolitis: 2014 AAP Guidelines

Case Continued

As you are wrapping up the visit, mom

asks if big brother Chervil needs his “TB shot” for first grade

You ask a few clarifying questions:

Last PPD when starting kindergarten was

negative

No travel, no active TB contacts, no chronic

medical conditions

TB SCREENING

Tuberculosis Screening

Universal Screening NOT recommended Those at high risk of disease OR

progression

Symptoms of disease, TB+ close contact HIV disease, immunosuppressed Travel to/immigration from/living with

immigrant from an endemic country, stay in jail/homeless shelter

TB screening in Kids

 PPD recommended for first line screening  BCG NOT a contraindication  Can use Interferon-gamma release assay (e.g.

Quantiferon) for confirmation if PPD+ with h/o BCG

 Threshold for positive PPD  5 mm if high risk (HIV +, abn CXR, contact w/ case)  10 mm if mod risk (<4, endemic area, medical

conditions (diabetes, renal failure), IV drugs, contact with high-risk adult)

 15 mm all others

Latent TB Treatment

Regimen options:

INH 10-15mg/kg/day x 9 months Consider INH + rifapentine/rifampin x 3

months if unlikely to complete primary regimen

Screening labs (i.e. LFTs) are not needed

in normal healthy children taking INH unless symptomatic

VACCINES

“An ounce of prevention is worth a pound of cure.”- Benjamin Franklin

Standard Schedule

Primary Series

Primary Series: Rotavirus

Primary Series: Hepatitis B

Primary Series: Boosters

Live Attenuated Vaccines

Influenza

Teen Vaccines

• MCV4 at 11 and 16yo
• TdaP at 11yo: required for 7th grade in CA
• HPV (2,4,9 valent): 3 doses
• Min age 9; 6 mo between 1st and 3rd

Vaccine Contraindications

 Serious reaction to previous dose  Anaphylaxis, encephalopathy w/in 7 days (DTaP)  Life-threatening allergy (anaphylaxis) to component  Neomycin (IPV, MMR, VZV)  Gelatin (MMR, VZV)  Egg (Influenza - both IIV and LAIV)  Yeast (Hep B, HPV)  Specific to Live Vaccines (RV5, MMR, VZV, LAIV)  Severe immunodeficiency: SCID, AIDS  Pregnancy  LAIV only: chronic illness (active asthma, CKD, heart disease)

cdc.gov/vaccines/recs/vac-admin/contraindicatons

Vaccination Precautions

 Weigh risk, benefits, alternatives with family

History of Guillain-Barre within 6 weeks of

previous vaccine (flu)

Progressive Arthus-type reaction after previous

dose of tetanus or diptheria containing vaccine

Unstable neurological condition (pertussis) Recent receipt of blood product (MMR, VZV) History of thrombocytopenia (MMR) DTaP: fever >105 or hypotonic hyporesponsive

episode or crying >3 hrs within 48 hours of previous dose

VISUAL DIAGNOSIS

Toddler with fever, refusing po’s drooling…

Hand- foot-mouth disease (coxsackie virus)

Examples of “atypical coxsackie”

Eurosurveillance.org Pediatrics.aapublications.org

5 yo comes back from camp with fever, cough and runny nose, then develops rash proceeding head to toe

PHASE TIME COURSE DESCRIPTION Prodromal 2-3 days Fever + 3 C’s: cough, coryza (runny nose), conjunctivitis Exanthem 3-5 days Erythematous macules proceed cranial -> caudal. May become confluent. Koplik spots Recovery 5+ days Fever subsides and rash fades

Measles

Measles

PHASE TIME COURSE DESCRIPTION Prodromal 2-3 days Fever + 3 C’s: cough, coryza (runny nose), conjunctivitis Exanthem 3-5 days Erythematous macules proceed cranial -> caudal. May become confluent. Koplik spots Recovery 5+ days Fever subsides and rash fades

Measles in the US

http://www.cdc.gov/measles/cases-outbreaks.html

201 6

Measles Fast Facts

 Droplet/airborne spread, ~90%  2 doses of vaccine = 97% effective  Dx by serology (IgM or rise in IgG) or PCR  High risk for severe illness = <5yo or >20yo,

pregnant, immunocompromised

 Severe/fatal complications:  Encephalitis: 1/1000  Resp/neurologic complication: 1-2/1000  Subacute sclerosing panencephalitis (SSPE): rare, 7-

10 years after infection

 No specific treatment (vit A for severe illness)

High fever for 3 days, defervesced then developed rash on chest head

Roseola infantum

Typically caused by Human Herpes Virus (HHV) 6 or 7

6 yo recently visiting grandparents in Boston, itchy rash:

Erythema migrans: early localized stage

• f Lyme Disease

7 yo with fever, sore throat now with dry, diffuse rash most pronounced

• n trunk and face

Group A Streptococcal “Scarlet Fever”

Spices of the World…

Serrano Aleppo Sorrel Sumac Chervil

References

Bradley, J. et al “The Management of Community- Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Disease Society of America.” Clin Inf Dis. 2011 Aug 30. Community acquired pneumonia guideline team, Cincinnati Children's Hospital Medical Center. Evidence-based care guidelines for medical management of community acquired pneumonia in children 60 days to 17 years of age. Guideline 14. Hamilton, J and Sony John “Evaluation of Fever in Infants and Young Children.” 2013 Feb 15;87(4):254-260 Lieberthal, A et al “The Diagnosis and Management of Acute Otitis Media.” Pediatrics 2012-3488 Marmor, A. “Recommendations for Management of Well- Appearing Infant with Fever Without a Source (FWS) in the Post- Pneumococcal Vaccine Era.” UCSF Pediatrics Clinical Guideline. September, 2015. Miller, EK et al. “Viral Etiologies of Infant Bronchiolitis, Croup and Upper Respiratory Ilness during 4 Consecutive Years.” Pediatric Infectious Disease 2013; 32 (9) 950-955. Ralston, S. et al, “Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis.” Pediatrics 2014- 2742. Roberts KB; “Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.” Pediatrics. 2011;128(3):595–610 Stuckey- Schrock, K. “Community Acquired Pneumonia in Children.” Am Fam Physician. 2012 Oct 1;86(7):661-667.